HEALTH

Whereas traditional medicine continued to play an important role in
Nigeria in 1990, the country made great strides in the provision of
modern health care to its population in the years since World War II,
particularly in the period after independence. Among the most notable
accomplishments were the expansion of medical education, the improvement
of public health care, the control of many contagious diseases and
disease vectors, and the provision of primary health care in many urban
and rural areas. In the late 1980s, a large increase in vaccination
against major childhood diseases and a significant expansion of primary
health care became the cornerstones of the government's health policies.

Nonetheless, many problems remained in 1990. Sharp disparities
persisted in the availability of medical facilities among the regions,
rural and urban areas, and socioeconomic classes. The severe economic
stresses of the late 1980s had serious impacts throughout the country on
the availability of medical supplies, drugs, equipment, and personnel.
In the rapidly growing cities, inadequate sanitation and water supply
increased the threat of infectious disease, while health care facilities
were generally not able to keep pace with the rate of urban population
growth. There were several serious outbreaks of infectious diseases
during the 1980s, including cerebrospinal meningitis and yellow fever,
for which, especially in rural areas, treatment or preventive
immunization was often difficult to obtain. Chronic diseases, such as
malaria and guinea worm, continued to resist efforts to reduce their
incidence in many areas. The presence of acquired immune deficiency
syndrome (AIDS) in Nigeria was confirmed by 1987 and appeared to be
growing.

History of Modern Medical Services

Western medicine was not formally introduced into Nigeria until the
1860s, when the Sacred Heart Hospital was established by Roman Catholic
missionaries in Abeokuta. Throughout the ensuing colonial period, the
religious missions played a major role in the supply of modern health
care facilities in Nigeria. The Roman Catholic missions predominanted,
accounting for about 40 percent of the total number of mission-based
hospital beds by 1960. By that time, mission hospitals somewhat exceeded
government hospitals in number: 118 mission hospitals, compared with 101
government hospitals.

Mission-based facilities were concentrated in certain areas,
depending on the religious and other activities of the missions. Roman
Catholic hospitals in particular were concentrated in the southeastern
and midwestern areas. By 1954 almost all the hospitals in the midwestern
part of the country were operated by Roman Catholic missions. The next
largest sponsors of mission hospitals were, respectively, the Sudan
United Mission, which concentrated on middle belt areas, and the Sudan
Interior Mission, which worked in the Islamic north. Together they
operated twenty-five hospitals or other facilities in the northern half
of the country. Many of the mission hospitals remained important
components of the health care network in the north in 1990.

The missions also played an important role in medical training and
education, providing training for nurses and paramedical personnel and
sponsoring basic education as well as advanced medical training, often
in Europe, for many of the first generation of Western-educated Nigerian
doctors. In addition, the general education provided by the missions for
many Nigerians helped to lay the groundwork for a wider distribution and
acceptance of modern medical care.

The British colonial government began providing formal medical
services with the construction of several clinics and hospitals in
Lagos, Calabar, and other coastal trading centers in the 1870s. Unlike
the missionary facilities, these were, at least initially, solely for
the use of Europeans. Services were later extended to African employees
of European concerns. Government hospitals and clinics expanded to other
areas of the country as European activity increased there. The hospital
in Jos, for example, was founded in 1912 after the initiation there of
tin mining.

World War I had a strong detrimental effect on medical services in
Nigeria because of the large number of medical personnel, both European
and African, who were pulled out to serve in Europe. After the war,
medical facilities were expanded substantially, and a number of
government-sponsored schools for the training of Nigerian medical
assistants were established. Nigerian physicians, even if trained in
Europe, were, however, generally prohibited from practicing in
government hospitals unless they were serving African patients. This
practice led to protests and to frequent involvement by doctors and
other medical personnel in the nationalist movements of the period.

After World War II, partly in response to nationalist agitation, the
colonial government tried to extend modern health and education
facilities to much of the Nigerian population. A ten-year health
development plan was announced in 1946. The University of Ibadan was
founded in 1948; it included the country's first full faculty of
medicine and university hospital, still known as University College
Hospital. A number of nursing schools were established, as were two
schools of pharmacy; by 1960 there were sixty-five government nursing or
midwifery training schools. The 1946 health plan established the
Ministry of Health to coordinate health services throughout the country,
including those provided by the government, by private companies, and by
the missions. The plan also budgeted funds for hospitals and clinics,
most of which were concentrated in the main cities; little funding was
allocated for rural health centers. There was also a strong imbalance
between the appropriation of facilities to southern areas, compared with
those in the north.

By 1979 there were 562 general hospitals, supplemented by 16
maternity and/or pediatric hospitals, 11 armed forces hospitals, 6
teaching hospitals, and 3 prison hospitals. Altogether they accounted
for about 44,600 hospital beds. In addition, general health centers were
estimated to total slightly less than 600; general clinics 2,740;
maternity homes 930; and maternal health centers 1,240.

Ownership of health establishments was divided among federal, state,
and local governments, and there were privately owned facilities.
Whereas the great majority of health establishments were government
owned, there was a growing number of private institutions through the
1980s. By 1985 there were 84 health establishments owned by the federal
government (accounting for 13 percent of hospital beds); 3,023 owned by
state governments (47 percent of hospital beds); 6,331 owned by local
governments (11 percent of hospital beds); and 1,436 privately owned
establishments (providing 14 percent of hospital beds).

The problems of geographic maldistribution of medical facilities
among the regions and of the inadequacy of rural facilities persisted.
By 1980 the ratios were an estimated 3,800 people per hospital bed in
the north (Borno, Kaduna, Kano, Niger, and Sokoto states); 2,200 per bed
in the middle belt (Bauchi, Benue, Gongola, Kwara, and Plateau states);
1,300 per bed in the southeast (Anambra, Cross River, Imo, and Rivers
states); and 800 per bed in the southwest (Bendel, Lagos, Ogun, Ondo,
and Oyo states). There were also significant disparities within each of
the regions. For example, in 1980 there were an estimated 2,600 people
per physician in Lagos State, compared with 38,000 per physician in the
much more rural Ondo State.

In a comparison of the distribution of hospitals between urban and
rural areas in 1980, Dennis Ityavyar found that whereas approximately 80
percent of the population of those states lived in rural regions, only
42 percent of hospitals were located in those areas. The maldistribution
of physicians was even more marked because few trained doctors who had a
choice wanted to live in rural areas. Many of the doctors who did work
in rural areas were there as part of their required service in the
National Youth Service Corps, established in 1973. Few, however,
remained in remote areas beyond their required term.

Hospitals were divided into general wards, which provided both
outpatient and inpatient care for a small fee, and amenity wards, which
charged higher fees but provided better conditions. The general wards
were usually very crowded, and there were long waits for registration as
well as for treatment. Patients frequently did not see a doctor, but
only a nurse or other practitioner. Many types of drugs were not
available at the hospital pharmacy; those that were available were
usually dispensed without containers, meaning the patients had to
provide their own. The inpatient wards were extremely crowded; beds were
in corridors and even consisted of mattresses on floors. Food was free
for very poor patients who had no one to provide for them. Most,
however, had relatives or friends present, who prepared or brought food
and often stayed in the hospital with the patient. By contrast, in the
amenity wards available to wealthier or elite patients, food and better
care were provided, and drug availability was greater. The highest level
of the Nigerian elite frequently traveled abroad for medical care,
particularly when a serious medical problem existed.

In the early 1980s, because of shortages of fuel and spare parts,
much expensive medical equipment could not be operated. Currency
devaluation and structural adjustment beginning in 1986 exacerbated
these conditions. Imported goods of all types doubled or tripled in
price, and government and public health care facilities were severely
affected by rising costs, government budget cuts, and materials
shortages of the late 1980s. Partly as a result of these problems,
privately owned health care facilities became increasingly important in
the late 1980s. The demand for modern medical care far outstripped its
availability. Medical personnel, drugs, and equipment were increasingly
diverted to the private sector as government hospitals deteriorated.

Government health policies increasingly had become an issue of policy
debate and public contention in the late 1980s. The issue emerged during
the Constituent Assembly held in 1989 to draft a proposed constitution.
The original draft reported by the assembly included a clause specifying
that free and adequate health care was to be available as a matter of
right to all Nigerians within certain categories. The categories
included all children younger than eighteen; all people sixty-five and
older; and all those physically disabled or handicapped. This provision
was, however, deleted by the president and the governing council when
they reviewed the draft constitution.

Primary Health Care Policies

In August 1987, the federal government launched its Primary Health
Care plan (PHC), which President Ibrahim Babangida announced as the
cornerstone of health policy. Intended to affect the entire national
population, its main stated objectives included accelerated health care
personnel development; improved collection and monitoring of health
data; ensured availability of essential drugs in all areas of the
country; implementation of an Expanded Programme on Immunization (EPI);
improved nutrition throughout the country; promotion of health
awareness; development of a national family health program; and
widespread promotion of oral rehydration therapy for treatment of
diarrheal disease in infants and children. Implementation of these
programs was intended to take place mainly through collaboration between
the Ministry of Health and participating local government councils,
which received direct grants from the federal government.

Of these objectives, the EPI was the most concrete and probably made
the greatest progress initially. The immunization program focused on
four major childhood diseases: pertussis, diphtheria, measles, and
polio, and tetanus and tuberculosis. Its aim was to increase
dramatically the proportion of immunized children younger than two from
about 20 percent to 50 percent initially, and to 90 percent by the end
of 1990. Launched in March 1988, the program by August 1989 was said to
have been established in more than 300 of 449 LGAs. Although the program
was said to have made much progress, its goal of 90 percent coverage was
probably excessively ambitious, especially in view of the economic
strains of structural adjustment that permeated the Nigerian economy
throughout the late 1980s.

The government's population control program also came partially under
the PHC. By the late 1980s, the official policy was strongly to
encourage women to have no more than four children, which would
represent a substantial reduction from the estimated fertility rate of
almost seven children per woman in 1987. No official sanctions were
attached to the government's population policy, but birth control
information and contraceptive supplies were available in many health
facilities.

The federal government also sought to improve the availability of
pharmaceutical drugs. Foreign exchange had to be released for essential
drug imports, so the government attempted to encourage local drug
manufacture; because raw materials for local drug manufacture had to be
imported, however, costs were reduced only partially. For Nigeria both
to limit its foreign exchange expenditures and simultaneously to
implement massive expansion in primary health care, foreign assistance
would probably be needed. Despite advances against many infectious
diseases, Nigeria's population continued through the 1980s to be subject
to several major diseases, some of which occurred in acute outbreaks
causing hundreds or thousands of deaths, while others recurred
chronically, causing large-scale infection and debilitation. Among the
former were cerebrospinal meningitis, yellow fever, Lassa fever and,
most recently, AIDS; the latter included malaria, guinea worm,
schistosomiasis (bilharzia), and onchocerciasis (river blindness).
Malnutrition and its attendant diseases also continued to be a
refractory problem among infants and children in many areas, despite the
nation's economic and agricultural advances.

Among the worst of the acute diseases was cerebrospinal meningitis, a
potentially fatal inflammation of the membranes of the brain and spinal
cord, which can recur in periodic epidemic outbreaks. Northern Nigeria
is one of the most heavily populated regions in what is considered the
meningitis belt of Africa, stretching from Senegal to Sudan and all
areas having a long dry season and low humidity between December and
April. The disease plagued the northern and middle belt areas in 1986
and 1989, generally appearing during the cool, dry harmattan season when
people spend more time indoors, promoting contagious spread. Paralysis,
and often death, can occur within forty-eight hours of the first
symptoms.

In response to the outbreaks, the federal and state governments in
1989 attempted mass immunization in the affected regions. Authorities
pointed, however, to the difficulty of storing vaccines in the harsh
conditions of northern areas, many of which also had poor roads and
inadequate medical facilities.

Beginning in November 1986 and for several months thereafter, a large
outbreak of yellow fever occurred in scattered areas. The most heavily
affected were the states of Oyo, Imo, Anambra, and Cross River in the
south, Benue and Niger in the middle belt, and Kaduna and Sokoto in the
north. There were at least several hundred deaths. Fourteen million
doses of vaccine were distributed with international assistance, and the
outbreak was brought under control.

Lassa fever, a highly contagious and virulent viral disease, appeared
periodically in the 1980s in various areas. The disease was first
identified in 1969 in the northeast Nigerian town of Lassa. It is
believed that rats and other rodents are reservoirs of the virus, and
that transmission to humans can occur through droppings or food
contamination in and around homes. Mortality rates can be high, and
there is no known treatment.

The presence of AIDS in Nigeria was officially confirmed in 1987,
considerably later than its appearance and wide dispersion in much of
East and Central Africa. In March 1987, the minister of health announced
that tests of a pool of blood samples collected from high risk groups
had turned up two confirmed cases of AIDS, both HIV Type-1 strains.
Subsequently, HIV-2, a somewhat less virulent strain found mainly in
West Africa, was also confirmed. In 1990 the infection rate for either
virus in Nigeria was thought to be below 1 percent of the population.

Less dramatic than the acute infectious diseases but often equally
destructive were a host of chronic diseases that were serious and
widespread but only occasionally resulted in death. Of these the most
common was malaria, including cerebral malaria, which can be fatal. The
guinea worm parasite, which is spread through ingestion of contaminated
water, is endemic in many rural areas, causing recurring illness and
occasionally permanently crippling its victims. The World Health
Organization (WHO) in 1987 estimated that there were 3 million cases of
guinea worm in Nigeria--about 2 percent of the world total of 140
million cases- -making Nigeria the nation with the highest number of
guinea worm cases. In affected areas, guinea worm and related
complications were estimated to be the major cause of work and school
absenteeism.

Virtually all affected states had campaigns under way to eradicate
the disease through education and provision of pure drinking water
supplies to rural villages. The government has set an ambitious target
of full eradication by 1995, with extensive assistance from the Japanese
government, Global 2000, and numerous other international donors.

The parasitic diseases onchocerciasis and schistosomiasis, both
associated with bodies of water, were found in parts of Nigeria.
Onchocerciasis is caused by filarial worms transmitted by small black
flies that typically live and breed near rapidly flowing water. The
worms can damage the eyes and optic nerve and can cause blindness by
young adulthood or later. In some villages near the Volta River
tributaries where the disease is endemic, up to 20 percent of adults
older than thirty are blind because of the disease. Most control efforts
have focused on a dual strategy of treating the sufferers and trying to
eliminate the flies, usually with insecticide sprays. The flies and the
disease are most common in the lowland savanna areas of the middle belt.

Schistosomiasis is caused by blood flukes, which use freshwater
snails as an intermediate host and invade humans when the larvae
penetrate the skin of people entering a pond, lake, or stream in which
the snails live. Most often, schistosomiasis results in chronic
debilitation rather than acute illness.